The Need for Coaches in the Clinical World

Abstract

and despair about change in clinical care, but I believe they all call for coaches—the need for facilitation in practice transformation.1,2 These studies offer important insights about facilitating behavior change, the importance of culture, respecting complexity, and the real risk that our nation’s quality payment program is mass delusion. Starting with the most promising, EvidenceNOW is an important, largescale test of change facilitation in frontline practice (Cohen et al).3 The integration of an evaluation plan (ESCALATES) and intense intention to learn was certainly part of its secret sauce, producing dozens of useful studies along the way. The manuscript in this issue reports on the role of practice conditions and facilitation on improving blood pressure and smoking cessation, finding that smaller and physician-owned practices are more likely to have sufficient agency and capacity for translating motivations into change and improvement than larger or system-owned practices. The authors find practice facilitation to be an important ingredient for change, but particularly in the latter clinics. This is an important lesson given the rapid shifts in practice ownership and health system consolidation. The paper adds to evidence for federal and state investments in practice facilitation and is also testament to a decade of careful, thoughtful investment by the Agency for Healthcare Research and Quality in learning how to support practice transformation. Caring for psychologically complex patients with pain and addiction is tough, but Sokol and colleagues found that an interdisciplinary consultation service can help primary care physicians in specific ways and reduce their burden.4 Like practice facilitation, pain and addiction supportive services (PASS) are not generally supported by current payment models, but it turns out that they are important for validating frontline clinician decision making and emotions in caring for this difficult patient population. They also give such patients a sense of more control, can lift some of the burden of management decisions, enable boundary setting, and contribute to learning how to reframe visits around patients’ functioning, values, and goals rather than their pain or medications. Access to services like PASS, offering coaching, consulting, and visit scripting may be important to increasing availability and quality of care for this important patient population. And we may need different consulting models to support the wide range of primary care practices. Reducing unnecessary antibiotic prescribing was an explicit system value when I was a medical student. As an effort, it continues to struggle despite an accumulation of research. Perera et al at University of Auckland nicely summarize much of this evidentiary landscape in framing a 3-arm RCT of testing in-office patient messaging.5 Specifically, they test 2 ways of potentially reducing patients’ expectations for antibiotic treatment of upper respiratory infections using a necessity-concern framework: The first message is about the futility of antibiotics (necessity); the second on the potential for adverse effects (concern). Practice doctors were aware of the study but not involved outside of usual care. Patients in both intervention arms were significantly less likely to expect antibiotics than the control group—but there were no differences in likelihood of receiving a prescription! Less than one-third of patients received such prescriptions (lower than typical), and some factors were associated with higher odds of receiving a prescription and filling it: (1) patients who strongly wanted antibiotics despite intervention; (2) perception that child’s illness was severe; or (3) those with ear pain. It will take patientand physician-focused interventions to further reduce antibiotic prescribing/receiving for upper respiratory infections, but at least now we have 2 more options for reducing patient expectations. Despite California policies excluding hospitals with high cesarean delivery rates from health insurance EDITORIAL